Development of Moral Reasoning during Medical Education Darko Hren, PhD Croatian Medical Journal and University of Split Croatia.

Development of Moral Reasoningduring Medical Education

Darko Hren, PhDCroatian Medical Journal and University of Split

Croatia

Moral reasoning(Neo-Kohlbergiann approach)

• 3 developmental schemae

P

PI

MN

PERSONAL INTERESTWhat each protagonist of a moral dilemma (or their significant other) has to gain or lose?

• Personal gain is the main issue• Includes only immediate surrounding

MAINTAINING NORMSTaking a broader societal perspective through adherence to norms, regulations and laws.

• Need for norms• Broader societal viewpoint• Uniform and categorical application of norms

POSTCONVENTIONALAdministration of moral ideals in a fully reciprocal way so that each member of society has an equal status

• Adhering to ideals• Generalizable ideals• Primacy of moral ideals

DEVELOPMENT OF MORAL REASONING DURING HIGHER EDUCATION

• Cross sectional studies: Rest (1979) – formal education explained 50% of variance in scores on a test of moral reasoning

• Longitudinal studies:Rest & Deemer (1986) – attending college explained 38% of variance in scores

• Educational orientation:Deemer (1987) – educational orientation explained 13% of variance in scores

• Review articles:King i Mayhew (2002) – more than 500 studies which addressed the issue of relationship between education and moral reasoning

MORAL REASONING AND MEDICAL EDUCATION

• No gains in moral reasoning scores:Self et al,1993; Self & Baldwin, 1994;Morton, 1996; Self, Olivarez & Baldwin, 1998

• Decline in scores:Patenaude et al, 2003

AIM

• Investigate the relationship between moral reasoning and medical education

INSTRUMENT

• DIT2 – Defining Issues Test (Rest et al, 1999)

• 5 short stories presenting a moral dilemma• After deciding, participants rate 12 questions for

importance in making a decision

• Scores for each schema (P, MN and PI)• Developmental profiles (predominant schema)

RESEARCH DESIGN

Year ofenrolment

2004

2003

2002

2001

2000

Times of measurement

200420032002

2nd yr.n=192

2nd yr.n=207

2nd yr.n=139

1st yr.n=131

3rd yr.n=153

4th yr.n=101

1999

5th yr.n=85

6th yr.n=77

Controlsn=298

• Same age span(18-27)• Never studied

Matchedn=75

Matchedn=61

RESULTS – AGE AND DIT2 SCORES

• Zero correlations between all DIT2 scores and age for both, medical students and controls

RESULTS – SEX AND DIT2 SCORES(M=0, F=1)

DIT2Scores

PMNPI

Med. Students

0.20*-0.12*-0.14*

Controls

0.12*-0.04-0.12*

SEX(M=0, F=1)

RESULTSScores of different generations of students at the same time point of their study

• no stat. sig. differencesP

MN

PI

Generations of students

RESULTSDifferencef between medical students on different study years

• stat.sig. difference between groups of students (F5,679=3.67, p=0.003, η2=0.03)

• stat. sig. quadratic trend (p=0.035)

• no stat. sig. differences (F5,679=0.83, p=0.527)

• stat.sig. difference between groups of students (F5,679=3.38, p=0.005, η2=0.03)

• stat. sig. reverse quadratic trend (p<0.001)

P

MN

PI

Year of study

RESULTSChanges in scores over time

• stat. sig. interaction between repeated measurements and developmental profiles at the first measurement (F1,129=14,87, p<0,001, η2=0,19)

• stat. sig. interaction between repeated measurements and developmental profiles at the first measurement (F1,129=12,58, p<0,001, η2=0,16)

• stat. sig. interaction between repeated measurements and developmental profiles at the first measurement (F1,129=8,25, p<0,001, η2=0,11)

P

MN

PI

GenerationI

n=75

Generation II

n=61

CONCLUSIONS

• ...they decrease when students enter clinical rotations, but...

• Medical students’ moral reasoning scores increase during preclinical years, but...

• ...they do not decrease below Maintaining Norms schema.

WHY?(a few speculations...)

• Clinical hierarchy

• Specific dilemmas which are not addressed• Feudtner & Christiakis (1993):

• LEARNING vs. PATIENT CARE• TEAM PLAYER vs. PERSONAL PRINCIPLES• QUESTIONING ROUTINES vs. ABSOLUTE IGNORANCE• PERSONAL KNOWLEDGE OF THE PATIENT vs. MEDICAL

KNOWLEDGE

• Hidden curriculum

• ...

WHAT CAN BE DONE?

• Small group case discussionso specific issueso as early as possible o at least 20 hours (Self et al, 1998)o vertical approacho related to students’ experiences

(critical incidents discussions)

WHAT ELSE?

• Social learning – teachers, mentors, elders, superiors...

• Hidden curriculum – research, awareness, direction

• Investigate all components which lead to moral behavior (moral sensitivity, moral reasoning, moral motivation, moral character), develop and evaluate interventions